Báo cáo y học: "The association of psychological stress and health related quality of life among patients with stroke and hypertension in Gaza Strip" pps

Open AccessPrimary research The association of psychological stress and health related quality of life among patients with stroke and hypertension in Gaza Strip Address: 1 Department of

Open Access

Primary research

The association of psychological stress and health related quality of life among patients with stroke and hypertension in Gaza Strip

Address: 1 Department of Psychiatry, School of Medicine, James Cook University, Australia, 2 Department of Psychiatry and Psychotherapy,

University of Munster, Germany and 3 Islamic University, Gaza, Palestinian Authority

Email: BT Baune* - bbaune@uni-muenster.de; Y Aljeesh - yjeesh@mail.iugaza.edu

* Corresponding author

Abstract

Background: The study was performed to investigate the association of psychological stress and

quality of life (QOL) among patients with the cardiovascular disease (CVD) of hypertension plus

stroke or hypertension only

Methods: The WHOQOL-BREF questionnaire was applied to 112 hypertensive patients with

hypertension plus stroke and 224 hypertensive patients without stroke Psychological stress was

assessed with SCL-90 Means scale scores were compared using student-t-test and predictors of

QOL were calculated with covariance analysis

Results: Patients with stroke had a significant lower QOL than patients without stroke and a

significantly higher level of stress (p < 0.01) In analyses of covariance psychological stress was

significantly correlated to all domains of QOL among non-stroke patients The same psychological

and sociodemographic factors showed little impact on the stroke patients in these multivariable

analyses In these models psychological stress had a significant impact on the global domain of QOL

among stroke patients Income and gender were the only sociodemographic factors being

significantly associated with the physical (education) and social (gender) domains of QOL in stroke

patients

Conclusion: Psychological stress was strongly correlated with all domains of QOL in patients

without stroke and was only partly associated with QOL among patients with stroke Future

studies should investigate if psychological stress is a factor suitable for educational and

psychological interventions aiming at stress reduction in CVD patients which might substantially

contribute to better health related quality of life in these patients

Background

Quality of life (QOL) is a phrase often used in health care

settings at policy and administration levels, in clinical

assessments of therapies, and in clinical management of

individual cases While QOL is a broad concept that

cov-ers such areas as social, environmental, economic, and

health satisfaction, health-related quality of life (HRQL) is less wide ranging, including mental and physical health and their consequences Health-related quality of life (HRQL) is considered as one of the key concepts in con-temporary practice of medicine and delivery of health care [1-4] Quality of life assessment is complicated by the fact

Published: 19 May 2006

Annals of General Psychiatry 2006, 5:6 doi:10.1186/1744-859X-5-6

Received: 20 October 2005 Accepted: 19 May 2006 This article is available from: http://www.annals-general-psychiatry.com/content/5/1/6

© 2006 Baune and Aljeesh; licensee BioMed Central Ltd.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

that there is no universally accepted definition for QOL.

The researchers of this study have adopted the WHO

def-inition of QOL which identifies QOL as a

multidimen-sional concept It is defined as "individuals' perceptions of

their position in life in the context of the culture and value

system in which they live and in relation to their goals,

standards, and concerns" [5]

In general, HRQL can be influenced directly and indirectly

by various disease related factors Chronic diseases, such

as cardiovascular diseases and mental disorders (e.g

depression) potentially decrease short-term and

long-term HRQL Direct effects of the disease itself and side

effects of the treatment may influence HRQL in patients

with stroke or hypertension Hypertension and stroke are

two prevalent medical conditions which may affect

qual-ity of life substantially Moreover, anti-hypertensive

med-ication may induce fatigue, dizziness, and sexual

dysfunction, which in turn impairs patient's activity of

daily living and quality of life [6-8] Sexual dysfunction is

not necessarily caused by the hypertensive drug therapy,

but is likely due to other factors such as vascular disease

[9]

Major medical consequences of stroke concern different

physical and psychological aspects such as loss of sense,

palsy, disturbance of body image, depression and change

in patient's role also affecting HRQL Despite of side

effects of medication (e.g antidepressant,

anti-choliner-gic, and anti-adrenergic agents) potentially leading to

decreased well-being [10], a meta-analysis of well-selected

and comparable trials has shown the positive impact of

anti-hypertensive medication on patient's quality of life as

a whole despite disturbing side effects [11] Grimm et al

showed in a study with patients suffering from mild

hypertension that anti-hypertensive medication improves

quality of life secondary to a reduction of blood pressure

[12]

The assessment of HRQL in this study is based on a

holis-tic and multidimensional approach of HRQL, which

includes several dimensions such as physical,

socioeco-nomic, spiritual and psychological aspects Stress is

among the psychological factors potentially influencing

QOL [3,4] Moreover, mental well-being is essential part

of the QOL concept and therefore part of the assessment

of quality of life carried out with e.g the SF36 instrument

or the WHOQOL questionnaire [5] In relation to

cardio-vascular diseases, psychological factors such as stress seem

to play an even more important role for patients' HRQOL

suffering from stroke or hypertension than patient

charac-teristics, blood pressure, or drug-related factors [14]

Psychological stress has been targeted in intervention and

rehabilitation programs among patients with

hyperten-sion, because it is believed that stress reduction can improve hypertension [15] Certain intervention pro-grams for stress reduction aimed successfully at a reduc-tion of blood pressure [15-17]

Despite the positive impact of medication on quality of life in hypertensive patients suffering from stroke or hypertension only recent research suggests paying more attention to psychological factors such as stress account-ing for quality of life among various cardiovascular disor-ders, because psychological stress seems to be an additional factor suitable for interventions aiming at improved HRQL for these patients [15]

However, little is known about the association of psycho-logical stress and health related quality of life among patients with various cardiovascular conditions To fur-ther investigate the relationship of psychological stress and quality of life among these patients, we carried out a study among patients either with hypertension only or hypertension plus stroke in Gaza

Objectives

This study investigates the impact of psychological stress

on health related quality of life (HRQL) among patients with or without stroke in Gaza Strip

Study design

A one to two matched case-control study was carried out The case group consists of 112 subjects with stroke and history of hypertension, and the control group consists of

224 subjects with hypertension only Cases and controls were matched by age, sex, starting point of therapeutic reg-imen for both pharmacological and non-pharmacological treatment, time of hypertension, enrollment location of hospital related health care clinics and calendar time For each case two identical controls were recruited to detect small differences between the two groups [18] and to compensate potential loss of controls

Patients and methods

Cases and controls were recruited from the same geo-graphical area in Gaza Strip [8,10] Three main hospitals

in Gaza Strip (Shefa, Nasser, and Khan Younis hospital) and the geographically and administratively related pri-mary health care clinics were pinpointed for the selection

of the study population Each selected primary health care clinic was associated with one of the three hospitals in relation to diagnostic and treatment as well as follow-up procedures The population under study was aged between 35 and 69 years The lower age limit was used, because hypertension and stroke considerably occur among people above 34 years of age in Gaza The upper limit was chosen because this is the average life expect-ancy in Gaza Strip Inclusion and exclusion criteria of the

study will be explicitly given below in the manuscript The

study was approved by the Ministry of Health in Gaza and

the local ethical committee in Gaza Strip

Inclusion and exclusion criteria

All available discharge data of patients from the selected

hospitals were screened for cases Patients who had been

hospitalized for acute stroke and history of hypertension

between 1st January and 31st December 2001 were defined

as cases (N = 180)

In total 112 (62%) hypertensive patients with stroke were

ultimately selected from the registers The diagnosis of

stroke was confirmed by a physician and a head CT scan

was performed Stroke was defined as "a sudden loss of

brain function resulting from disruption of the blood

sup-ply to a part of the brain" [2] A computed tomography

head scan had been carried out in patients with

hyperten-sion plus stroke Both groups were selected only, if a

his-tory of other physical diseases (diabetes, myocardial

infarction, atrial fibrillation, pulmonary oedema, asthma)

was excluded Sixty-eight (38%) out of 180 selected cases

were excluded from the study: 19 (28%) died after first

stroke; eighteen (26%) had a second stroke; seven subjects

(10%) were over 69 years old; 10 (15%) participated in

the pilot study; seven (10%) patients had no computer

tomography head scan; four (6%) refused to participate in

the study; three (4%) patients started their therapeutic

regimen less than one year

Controls were defined as having hypertension only,

with-out history of stroke prior to interview Hypertension was

defined when the threshold levels of 140 mm Hg systolic

and 90 mm Hg diastolic were reached at three different

independent measurements within one week, repeated

twice over a 2 months period prior to the diagnosis of

hypertension Further grading into mild, moderate, severe

hypertension was not made

Controls may have developed stroke later on after the

study period The occurrence of potential later

develop-ment of stroke in controls after the interview was studied

for the period of the study by telephone follow-up

inter-view and clinic visits During the period of the study no

one of the controls developed a stroke

These patients with a diagnosis of hypertension received

health care follow-up because of anti-hypertensive

medi-cation in eight governmental primary health care clinics

Controls were selected from the same primary health care

clinics where cases used to receive follow-up

appoint-ments for hypertension on primary health care level

before hospital admission due to the development of

stroke

Questionnaires

The first part of the questionnaire gives information on age, gender, marital status, education and socio-economic status Quality of life for the period 2 weeks prior to the interview was assessed with the brief version of the WHO Quality of life questionnaire [12,13] Psychological stress two weeks prior to the interview was assessed using five psychological items with a 5-level scale ranging from none to very strong (0–4) adapted from the Symptom Check List by Derogatis (SCL-90) with regards to (1) nerv-ousness, (2) paranoia, (3) social phobia, (4) criticism and (5) loneliness [19] According to the evaluation of the SCL-90 items, high scores on each of these psychological factors express psychological stress As no cut-off-points exist for psychological stress measured with the SCL-90, low stress is indicated by numbers pointing to '0' and high psychological stress is characterized by numbers pointing

to '20' The sum score (scale from 0–20) was used as a continuous variable in the analysis of covariance

The short version of the WHO Quality of life (WHOQOL-BREF) assessment gives means of four single domains (physical, psychological, social, and environmental) and one overall domain (global value) The range of each domain of QOL is from 0–100 As no cut-points exist for good and poor QOL measured by WHOQOL-BREF, poor quality of life is indicated by numbers pointing to '0' and high quality is characterized by numbers pointing to '100'

A certified translation of the questionnaire from English into Arabic language including a backward translation was performed twice independently, and the results were checked for inconsistencies

Statistical analysis

Frequency tables were calculated to describe the study population regarding sex, age, level of stress and quality of life The statistical significance of differences between groups was tested with Mann-Whitney-U-test (tables 2 and 3) Each quality of life domain was correlated with the continuous variable psychological stress by the use of Spearman's correlation coefficient (table 3)

Finally, analysis of covariance was carried out for each sin-gle domain of QOL separate for patients with hyperten-sion plus stroke and with hypertenhyperten-sion only (tables 4 and 5) In these separate covariance models the QOL domains served as the dependent variables and age (continuous variable), gender, education (5-level categorical variable), income (5-level categorical variable) and psychological stress (continuous variable with a scale ranging from 0– 20) served as covariates For all statistical procedures SPSS statistical software, version 12.0 was used

Study population

In table 1 the distribution of age and gender by diagnosis

is presented Approximately 70% of the stroke patients

had a cerebral infarction and 30% a hemorrhagic

infarc-tion The mean age of the study population was 55 years

(SD 6.6) Males (51.8%) were only slightly more frequent

than females in the study population (48.2%) The

partic-ipants were 40–69 years old Patients from 52 to 63 years

accounted for 57% of the age distribution One-fourth

(24%) of the patients were over 63 y Patients aged 45

years old or younger were the smallest group in the study

Education and income per month

The distribution of educational qualifications and of

aver-age monthly income stratified by disease status is

pre-sented in Table 2 The level of education was significantly

different between patients with hypertension plus stroke

and those with hypertension only (p = 0.001) Patients

with hypertension were generally higher qualified than

those with hypertension plus stroke Whereas nearly 60%

of patients with hypertension plus stroke presented

with-out a formal qualification (e.g., primary, preparatory,

sec-ondary school, University degree), only a little more than

one third (37.5%) among the patients with hypertension

was formally not qualified Although we found a trend

that patients with hypertension only had a larger

propor-tion of lower average monthly income compared to their

counterparts, this difference was not statistically

signifi-cant Furthermore, the results indicate a financially

under-privileged population under study: more than 75% of the

probands had a monthly income of 350 U.S $ or less

(Table 2)

Psychological stress, clinical, social and demographic

factors

Table 3 presents mean comparisons of the domains of

quality of life stratified by diagnosis, gender, education

and income Mean comparisons were made with

student-t student-tesstudent-t The resulstudent-ts show sstudent-tastudent-tisstudent-tically significanstudent-t poorer qual-ity of life across all domains among patients with the diag-nosis of hypertension plus stroke, female gender, and among those with low education and low income com-pared to their counterparts Psychological stress was statis-tically significant inversely correlated with the physical, psychological, social, environmental and global domains

of QOL

Age had no significant impact on any of the domains of QOL (data not shown)

Association of psychological stress and QOL

Tables 4 and 5 present results of separate analyses of cov-ariance estimating the impact of psychological stress and other factors on domains of QOL separate for patients with hypertension only and those with hypertension plus stroke

Psychological stress was statistically significant correlated with all domains of QOL in patients with hypertension (Table 4) While gender was significantly correlated with the psychological, social, environmental and global domain of QOL among patients with hypertension, no such significant association was found for age Education was significantly related to all single domains of QOL (except the global value) Income showed a significant association with the physical, psychological, environmen-tal and global domain, but not with the social domain among patients with hypertension only (Table 4)

A different picture resulted from the analysis of covariance for patients with hypertension plus stroke (Table 5) Psy-chological stress was significantly correlated with the glo-bal domain only and income was significantly associated with the physical domain of QOL Gender was signifi-cantly associated with quality of life in the social domain

Table 1: Gender and age among stroke and non-stroke patients

Stroke (N = 112)

Non-stroke (N = 224)

Gender

The variables education and age were not significantly

correlated to any of the domains of QOL among patients

with hypertension plus stroke (Table 5)

Discussion

In this study we investigated the association of psycholog-ical stress and quality of life among patients suffering from the chronic and potentially disabling cardiovascular conditions of hypertension or hypertension plus stroke

Table 2: Education and average income in $ per month among stroke and non-stroke patients

Stroke (N = 112) Non-stroke (N = 224) Mann-Whitney-U-test

Level of education

Average income per month in

U.S $

Less than 200 U.S $ 48 (42.9) 101 (45.1)

Table 3: Clinical and sociodemographic factors and psychological stress by domains of quality of life

Domains of quality of life d

Characteristics Physical Mean (SD) Psychological Mean

(SD)

Social Mean (SD) Environmental

Mean (SD)

Global Mean (SD)

Diagnosis

Stroke 41.26 (15.49)*** 40.47 (15.31)*** 51.04 (17.37)*** 46.04 (17.41)*** 45.2 (23.14)*** Non-stroke 67.45 (15.69) 64.76 (17.19) 71.25 (15.03) 61.71 (15.26) 65.46 (18.58) Gender

Male 61.99 (19.38)*** 61.09 (19.97)*** 68.15 (17.98)*** 60.35 (17.86)*** 62.36 (21.51)*** Female 55.25 (19.95) 51.9 (19.28) 60.59 (18.25) 52.33 (16.41) 54.78 (22.60) Education a

Low 54.84 (19.31)*** 53.24 (18.50)*** 61.87 (17.66)*** 52.59 (16.18)*** 55.45 (21.83)*** High 68.93 (17.83) 65.59 (21.56) 71.42 (18.85) 66.63 (17.25) 67.20 (21.49) Income b

Low 54.46 (18.45)*** 51.15 (19.01)*** 61.41 (17.61)*** 51.20 (16.43)*** 54.78 (22.02)*** High 62.15 (20.42) 61.05 (19.98) 66.98 (18.82) 60.69 (17.43) 61.83 (22.14) Psychological stress c -0.339 *** -0.247 *** -0.231 *** -0.245 *** -0.284 *** p-value of Mann-Whitney-U-test: * not significant; ** p < 0.05; *** p < 0.01;

a Level of education (highest degree) was classified into two groups: low level = 'no education' or 'primary school' or 'preparatory school' high level

= 'secondary school' or 'University degree';

b Level of income per month: low level = income < 200 U.S $ per month; high level = income of >200 U.S $ per month;

c Spearman's correlation coefficient of the continuous variables stress and domains of QOL; p-value of correlation coefficient: * not significant; ** p

< 0.05;

d range of scale of domains of QOL: 0 = poorest QOL; 100 = best QOL;

In general, patients with hypertension plus stroke rated

statistically significant lower quality of life than their

purely hypertensive counterparts In the analyses of

covar-iance we found that psychological stress was significantly

related to all domains of QOL among patients with

hyper-tension Contrary, psychological stress had no major

effect on domains of QOL among hypertension plus

stroke patients in these multivariable models

Several other studies confirm the finding that patients

with hypertension plus stroke have lower QOL than those

with hypertension only due to the disabling effects of

stroke [20-22] In more general terms, Kempen et al

showed that health related quality of life is substantially

affected by chronic medical morbidity, such as stroke and

hypertension [22] Especially the disabling effects of

stroke may have an effect on reduced QOL even 1 year

after stroke as reported by Wyller et al [24] However,

findings on QOL and hypertension may be biased by a

underreporting Studies by MacDonald et al and Stein et

al showed that hypertensive patients tend to

underesti-mate the impact of hypertension on quality of life [24,25]

This tendency of underestimation in hypertensive patients

may also have occurred in our study and my have

influ-enced the marked differences of perceived quality of life

between patients with hypertension plus stroke and patients with hypertension only in our sample

Another main finding of this study is that psychological stress was related to all domains of quality of life among hypertensive patients This result confirms findings in a study from Ames et al among hypertensive patients stat-ing that quality of life is associated with psychological stress, even when accounted for age and number of chronic illnesses [15] As stress is part of lifestyle it has been shown by McDonald that high self perceived stress was related to uncontrolled hypertension [24] These results are important in light of potential interventions aiming at stress reduction in hypertensive CVD patients Carlson et al demonstrated that stress reduction enhanced quality of life in outpatients with breast cancer [26], but studies lack for the impact of such interventions

on QOL in CVD patients Thus, stress-reducing techniques might be particularly helpful in the setting for sive and stroke patients aiming at a reduction of hyperten-sion, at lowering the risk for (re-)stroke due to hypertension and subsequently to an improved quality of live [15-17]

The results from our study on the relationship between quality of life and socio-demographic characteristics

Table 4: Analysis of covariance for the impact of psychological stress, demographic and social factors on domains of quality of life among patients with hypertension

Domains

of QOL

Factors F-value (df) p F-value (df) p F-value (df) p F-value (df) p F-value (df) p Stress 9.3 (1) 0.00 5.2 (1) 0.02 7.9 (1) 0.005 5.4 (1) 0.02 4.6 (1) 0.03 Age 0.09 (1) 0.77 0.04 (1) 0.83 0.5 (1) 0.48 0.24 (1) 0.63 0.1 (1) 0.75 Gender 2.6 (1) 0.11 16.1 (1) 0.00 9.4 (1) 0.002 5.02 (1) 0.03 4.02 (1) 0.04 Education 4.5 (5) 0.00 2.9 (5) 0.02 2.9 (5) 0.01 3.5 (5) 0.00 0.93 (5) 0.47 Income 5.7 (3) 0.00 5.1 (3) 0.00 1.7 (3) 0.16 9.1 (3) 0.00 3.5 (3) 0.02 F-value = value of covariance analysis; df = degree of freedom; p = level of significance

Table 5: Analysis of covariance for the impact of psychological stress, demographic and social factors on domains of quality of life among patients with stroke

Domains

of QOL

Factors F-value (df) p F-value (df) p F-value (df) p F-value (df) p F-value (df) p Stress 2.9 (1) 0.09 0.00 (1) 0.99 0.08 (1) 0.88 1.8 (1) 0.21 5.3 (1) 0.02 Age 1.7 (1) 0.21 2.6 (1) 0.10 0.07 (1) 0.83 0.7 (1) 0.42 1.6 (1) 0.12 Gender 2.8 (1) 0.83 1.5 (1) 0.22 3.9 (1) 0.05 2.5 (1) 0.12 2.2 (1) 0.14 Education 1.5 (5) 0.21 1.1 (5) 0.37 0.4 (5) 0.85 2.1 (5) 0.07 0.55 (5) 0.74 Income 2.8 (3) 0.04 2.0 (3) 0.12 1.6 (3) 0.22 1.2 (3) 0.34 1.3 (3) 0.26 F-value = value of covariance analysis; df = degree of freedom; p = level of significance

among patients with hypertension plus stroke are partly

contrary to findings from Wyller et al who reported

female gender and a good social network as correlates of

subjective well-being one year after stroke [26] In our

study we found only particular evidence for this

correla-tion: gender had an impact on the social domain of QOL

and income on the physical domain of QOL among

patients with hypertension plus stroke Other

sociodemo-graphic characteristics such as age and education showed

no significant impact on any domain of QOL among

hypertension plus stroke patients

While education had no significant impact on any of the

QOL domains among patients with hypertension plus

stroke, we found a statistically significant correlation

between education and several domains of QOL among

patients with hypertension These results become

mean-ingful in light of Dressler's study, who reported, that lower

education was associated with high blood pressure and

high mortality from cardiovascular disease [28]

Accord-ing to these findAccord-ings it can be hypothesized, that

educa-tional interventions on healthy life styles may play an

essential part in the prevention of high blood pressure

and fatal cardiovascular events

Special characteristics of the Palestinian political and

eco-nomic situation may have contributed to these findings

indicating the significant relation of QOL and income and

education in Gaza Strip Unemployment and poverty are

the strongest challenges hampering human development

in Gaza Strip [29]

The demonstrated gab in quality of life between males

and females in our study may also be due to the

Palestin-ian male-dominant culture, but also due to additional

gynecological problems, and physiological differences

(menstruation, child birth, and menopause), which affect

women's health both physically and mentally The

Cent-ers for Disease Control and Prevention supports this

find-ing with their statement that decreased health related

quality of life is a particularly important issue among

women [30] In addition, Barajas et al found that female

gender and low level of education were significantly

asso-ciated with worse scores of quality of life in primary care

patients with obesity [31]

Limitations of the study

The duration of treatment of hypertension or stroke was at

least 1 year at the time patients were included into the

study No more medical details on the course of the

dis-ease in the previous year, on the type of brain lesion of

stroke or the severity of the CVD condition potentially

influencing QOL were obtained However, for the

pur-pose of this study which was to measure the association of

psychological stress and QOL, it was important to have

relatively stable medical conditions of hypertension and stroke It was assumed that the medical condition of hypertension or hypertension plus stroke with the dura-tion of at least one year had been chronic and relatively stable when patients were interviewed However, we were not able to take the drugs patients were taking into account since pharmacotherapy used in hypertension or

in stroke may impair quality of life

The cross-sectional design of the study does not allow for any stable prospective conclusions on the relationship of CVD conditions and QOL, although QOL was measured after the onset of the disease

The presented data showed that the selected variables (age, gender, income, education and psychological stress) largely explained the variance of the single domains of the QOL in hypertensive but not in hypertensive plus stroke patients Future research could focus on further explana-tory variables for quality of life in patients with hyperten-sion plus stroke or hypertenhyperten-sion only, such as cognitive and psychological (e.g orientation, memory, attention, concentration, language) factors with impact on general functioning, general well-being and QOL Previous research suggests addressing neuro-psychological features

in QOL research might be beneficial as these factors are suitable for the rehabilitation of CVD patients [32]

Conclusion

It can be concluded that QOL in patients with hyperten-sion plus stroke is likely to be more influenced by the dis-abling effect of stroke itself, and it appears to be less attributable to psychological stress and sociodemographic factors than in patients with hypertension Future research

is needed to confirm these results

As psychological stress is a modifiable risk factor, inter-ventions aiming at stress reduction in hypertensive patients might substantially contribute to a better quality

of life and to the prevention of stroke in hypertensive patients

Declaration of competing interests

The author(s) declare that they have no competing inter-ests

Authors' contributions

BB conceived the study, designed and developed the ques-tionnaire, performed statistical analysis and drafted the manuscript YA conceived the study and participated in the design and development of the questionnaire, co-ordinated and carried out the data collection in Gaza and helped to draft the manuscript All authors read and approved the final manuscript

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Acknowledgements

We are grateful to our patients, and to medical staff in hospitals and

pri-mary health care clinics in Gaza for their help to recruit them.

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